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HomeMy WebLinkAbout0104DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 3.19 -1 -90 BOX 2 _ I r or F 'T �� F li e ,., AL I 00104 bO It PUTNAM COUNTY DEPARTMENT OF HEAL DIVISION OF ENVIRONMENTAL HEALTH SERVICES CERTIFICATE OF CONSTRUCTION COMPLIANCE FOR SEWAGE TREATMENT SYSTEM PCHD CONSTRUCTION PERMIT # Located at 3,1 go ", <'d <iown >r Village A4T4?0sC-?/ Owner /Applicant Name �� 1� �rs�t ve�,y4, ;T aax Map's If Block / Lot fly Formerly Subdivision Name Subd. Lot # 6 Mailing Address 30Y /t'Zaie % Date Construction Permit Issued by PCHD �39 �fg1f�•�.t£ � Separate Sewerage System built by &z,, /,o ,,-w - Address FGY � Consisting of 19 r-� Gallon Septic Tank and 6 4� 2 4 /•� C - 1���'' Other Requirements: Water Supply: Public Supply From Address or: JC Private Supply Drilled by ,,�ys7- /��,E, Address Building Type S/ r: ,4 47 ey� Has erosion control been completed? Number of Bedrooms 'a' Has garbage grinder been installed? Xd IZ„!, I certify that the system(s), as listed, serving the above premises were constructed essentially as shown on the as- built plans (copies of which are attached), in accordance with the issued PCHD Construction Permit and approved plans and the standards, rules and regulations of the Putnam County Department of Health. Date: Certified by P. E. �� R.A. (Design Professional) Address laQ' y�,� � Z-- f „/� �P� /-14 7' C, 0IE 1601' License # �j`f� Any person occupying premises served by the above system(s) shall promptly take such action as may be necessary to secure the correction of any unsanitary conditions resulting from such usage. Approval of the separate sewage treatment system shall become null and void as soon as a public sanitary sewer becomes available and the approval of the private water supply shall become null and void when a public water supply becomes available. Such approvals are subject to modification or change when, in the judgment of the Director /Commissioner, such revocation, modification or change is necessary. By Title: Date: G- Wh to opy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional Form CC -97 �I i C3f p m v- I� IW I � Iw Iz .° I Wl o 0 I CL I W rnl ~ �I N I � . - N 00'10'00" E 1 11.00' ld A00 11.00' N , j 10OX EXPANSION AREA j END OFJ'RENCH JB -1❑ 3 4 I -Mp) , 6 JB _2- - - - - - - 7 11 ❑ - - . - - . - - - - - - - 'i 5 - - - -- 10 9 JB -3 ' 12 JB -4 3 11 ----- -- - - - - -- o -- --------- - - - -;s C .- - -- 15 JB_ -5 - - - - - -- O 14 ------ -- - - - - -- 18 JB- 6------- 19 I'i Rl 17 --------- -- - - -2 ❑ IB =� - - - -- - - - -2Z co- - -- ❑ - - - - - - - �---- - - - - -- 24 JB -8 25 , Z. 23 - - - - - - - - - - - - - ❑---------------- D -BOX DOSING CHAMBER W/ SIPHON 2 1 1250 GAL CON STEPS BC PLAT SEPTIC TANK 0 i CONCRETE A 4" C.I. PIPE STEPS & WALLS q TWO STORY s� FRAME DWELLING RAISED WOOD DECK 00 �o EXISTING WELL i I t � r I 0 Q) 0 E&A SSTS AS BUILT SITUATE IN THE TOWN of PATTERSON PUTNAM COUNTY NEW YORK SCALE: 1 "= 30' SURVEYED: SEPTEMBER 4, 2015 O PREMISES ARE DESIGNATED ON THE TAX MAPS FOR THE TOWN OF PATTERSON SECTION; 3.19 BLOCK; 1 LOT; 90 SSTS TIE IN (SURVEYED) UNIT A B SEPTIC TANK 1 34.6 370 DOSING CHAMBER 2 24.6 47.5 . JB -1 3 72.7 80.4 END OF TRENCH 4 99.5 73.0 END OF TRENCH 5 63.2 108.2 JB -2 6 66.1 76.2 END OF TRENCH 7 93.6 66.5 END OF TRENCH 8 57.7 104.9 JB -3 9 60.3 71.2 END OF TRENCH 10 8918 60.7 END OF TRENCH 11 52.7 102.1 JB -4 12 53.8 67.6 END OF TRENCH 13 86.0 54.7 END OF TRENCH 14 48.7 100.2 JB -5 15 48.6 63.3 END OF TRENCH 16 1 81.9 48.7 END OF TRENCH 17 43.6 97.9 JB -6 18 43.4 59.1 END OF TRENCH 19 78.2 42.7 END OF TRENCH 20 39.2 96.1 JB- 7 21 37.0 54.4 END OF TRENCH 22 75.5 36.6 END OF TRENCH 23 35.7 94.8 J6-8 24 33.2 51.6 END OF TRENCH 1 25 1 72.7 30.6 D -BOX 1 26 1 29.1 50.0 LENGTH OF PERORATED PIPE 44.5 FT TYPICAL TOTAL LENGTH OF FIELDS: 667.5' LENGTH OF TRENCH 48.0' TYPICAL PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES GUARANTEE OF SUBSURFACE SEWAGE TREATMENT SYSTEM qi-f . / ?_) Owner or Purchaser of Building Tax Map Block Lot Building Constructed by o illage Location — Street Subdivision Name Building Type Subdivision Lot # I represent that I am wholly and completely responsible for the location, workmanship, material, construction and drainage of the sewage treatment system serving the above - described property, and that it has been constructed as shown on the approved plan or approved amendment thereto, and in accordance with the standards, rules and regulations of the Putnam County Department of Health, and hereby guarantee to the _owner, his... successors, heirs or assigns, to place in good operating condition any part of said system constructed by me which fails to operate for a period of two. years immediately following the date of approval of the "Certificate of Construction Compliance" for the sewage treatment system, or any repair made by me to, such system, except where the failure to operate properly is caused by the willful or negligent act of the occupant of the building utilizing the system. The undersigned further agrees to accept as conclusive the determination of the Commissioner of Health of the Putnam County Department of Health as to whether or not the failure of the system to operate was caused by the willful or negligent act of the occupant of the bui g g the system. Dated: Month Year Signature: is y Installer) Title: Ge n act r (Owner) — Signature PCHD License # Corporation Name (if corporation) 'Corporation,Tame (if corporation) . , , /jam State: Zip �7 T� State: , � Zip (� 7 Form ALLEN SEALS, M.D., J.D. Commissioner of Health ROBERT MORRIS, P.E., MPH Director of Environmental Health October 19, 2015 Daniel J. Donahue, P.E. 120 Breckenridge Road Mahopac, NY 10541 Dear Mr. Donahue: DEPARTMENT OF HEALTH 1 Geneva Road, Brewster, New York 10509 Phone # (845) 808 -1390 Fax # (845) 278 -7921 Re: MARYELLEN ODELL County Fxecutive Construction Compliance — Patterson Development 34 Burton Farm Road (T) Patterson, T.M.. 3.19 -1 -90 This office has received and reviewed the most recent set of plans for the above - mentioned project. We would like to offer the following comments for your review and consideration. 1. The E -911 form has not been completed and signed by a Town of Patterson representative. 2. Two more copies of the SSTS guarantee form are to be provided. This office will continue its review upon consideration of the above - mentioned comments. Please feel free to contact me at (845) 808 -1390, ext. 43157. Sincerely, G oseph S. Paravati, Jr. P.E. Assistant Public Health Engineer JSP:cw cc: BI, (T) Patterson BRUCE R FOLEY Pubhc Health Dtrecxr DEPARTitiIENT OF HEALTH 1 Geneva Road . Brewster. Now York 10509 LORETTA MOLNAn R.N.. NUN. Rsaociate Public KealtA Diractcr D[rsetor of Pat;a>tt Servtcrs Mayiroameatal Health (914)278.6130 Pot (914) 278 -7921 'NutsltsA Sorvlea (9 141 277 -6558 WIC (4l4) 278.56,'8 Fax (914) 278 - 6081 Early Interveaclatt (914)2',3-6014 ?rachoal (914) 2186082 Fax (914) 278-- 6648 . MUM w 11 S 1 \ "EVIUM OWNERS NAME: -f,�srry TA-Y MAPiNU. NEB ER: E911 ADDRESS: 47 r AUrHORUED TOWN OFFICIAL: (Sianature) DATE: /e9aZI; The Putnam County Depa.rtment of Health will not issue a Certificate of Construction Compliance unless fhe above form is completed, i.e., a legal E911 address.is assigned by an authoA ed town official. This form is to be submitted -*ith the application for a Certificate of Construction Compliance. PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES WELL COMPLETION REPORT Well Location Street Address: Town /Village: Tax Map # Map3,1 q Block / Lot(s)q a GPS Well Owner: Name: Address: Use of Well: 1- Primary 2- Secondary ✓ Residential _Public Supply Air cond /heat pu p _Irri ation Business Farm Test/monitoring —Other(specify) Industrial Institutional Standby Drilling Equipment Rotary _Cable percussion Compressed air percussion Other(specify) Well Type Screened Yopen end casing _ Open hole in bedrock _Other Casing Details Total Length eft. '' ��cC u Length below gra ft. Diameter 4 in. Weight per foot 16 lb/ft Materials: teel Plastic Other Joints: Welded Threaded Other Seal: A.Cement grout Bentonite Other Drive shoe: Yes No Liner: _Yes No Screen Details Diameter (in) Slot Size Length (ft) Dept to Screen t) Developed? First Yes No Hours Second Well Yield Test _Bailed _Pumped Compressed Air Hours 74- Yield gpm Depth Date Measure from an su ace - static specs k During yield test Depth of comp ete we m . Well Log If more detailed information descriptions or sieve analyses are available, please attach. Depth From Surface Water Bearing Well Diameter in Formation Description ft. ft. Land Surface v O ; If yield was tested at different depths during drilling list: Feet Gallons Per Minute Pump /Storage Tank Information Pump Type J k6 k* .4j Capacity s .tZ Depth o Modell 7y 1Z Voltage as o HP Tank Type W X k� a Volume `L Date well completed x ell er d� �y r NY State , a , Pump Installer PC Certificate # °< / Jam= _NY States# %�02 b� _ WeII Driller Name 8 Address' z mad arm r r ✓7 3 " .#3 ,i, i x'd4i'' S K : K d k Y`yv -Y Y �Y gYy Y"'y{� �i.:, i 6 ` ✓ �3�: f ����I ����£3'z�� dM.Wb.� � �� �• �%.`Mtli �� " -.a.�j 'fi� ' Driller (st nature �aa g ) e�Tr�. xd:. '�� �£ YY k..# srer..�.5 �.il *r.x, Pump InstallerName8Address %� � :J Y ''. W.�,. e� R RR✓ ` 3: 1,: ,xl K� S' ki ik'ih "..'�" 1F' V,y: ✓V umpinsta ler (signature) .i1"i NOTE: Exact Location of well with distances to of least two permanent landmarks 1 be p�vided on a separate sheet/plan. White copy: HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WC -97 Rev. 3/06 ONSULTIN-G- NGINEERS -1 Daruel 1, Donahue, P.E. 2.00 Breckenridge Road Mahop&c. N.Y. 10341 914. 628-7576 TO WE ARE SENDING YOU C ,Attached f-1 Under 30081`06 COW r7.1 shop drawings Copy of letter E" Prints [� Change order 'E (T& 11"M '207 rLZTrTLEL T 'I Z I !� Mrk I 91X CL 41 Z—e [I Plans 71 Samples the following items. cl Specifications coolts DA se ION 0 ApMved as submitted (.71 Rosubmit.—copies for approval For your use 0 Approved as rooted C] Submit copies for distribution (3 ef D Returned for correction!) Return._ -- prints Cj For review and comnwt C! FOR BIDS DUE THESE ARE TRANSWIMED as checked below: For approval 0 ApMved as submitted (.71 Rosubmit.—copies for approval For your use 0 Approved as rooted C] Submit copies for distribution (3 As requested D Returned for correction!) Return._ -- prints Cj For review and comnwt C! FOR BIDS DUE PRINTS RETURNED AFTER LOAN TO US J41 MINED: if theMurts are not as 4616d, kimay ftr4oy we W, ones. YML ENVIRONMENTAL SERVICES 321 Kear Street Yorktown Heights, N.Y. 10598 (914) 245 -2800 Albert H. Padovani, Director ** TEST REPORT ** LAB #: 9.500519 CLIENT #: 64219 NON STAT PROC PAGE: 1 of 2 PATTERSON DEV PO( BOX 839 MAHOPAC, NY CORP 10541 DATE /TIME TAKEN: 09/14/15 12:15P DATE /TIME RECD: 09/14/15 01:OOP REPORT DATE: 09/28/15 PHONE: (914)- 403 -6220 SAMPLING SITE: 34 BURTON FARM RD, PATTERSON NY SAMPLE TYPE..: POTABLE KITCHEN TAP PRESERVATIVES: HNO3 COLD BY: MARK PORCELLI TEMP RECEIVED: 5.7C ON ICE NOTES...: COLIFORM METH: MF START DATE /TIME END DATE /TIME FLAG PROCEDURE RESULT NORMAL - RANGE METHOD PUTNAM CNTY PROFILE 09/14/15 0430 09/15/15 0330 MF T. COLIFOR ABSENT /100 ML ABSENT- SM 18 -20 9222B 09/22/15 LEAD (IMS) <1.0 ppb 0 -15 ppb SM 18 -19 3113B 09/15/15 0900 09/15/15 0930 NITRATE NITRO 2.40 MG /L 0 - 10 HACH 10206 09/15/15 0930 09/15/15 1000 NITRITE NITRO <0.01 MG /L 1.0 MG /L SM18- 20450ONO2 09/23/15 IRON (Fe) <0.06 MG /L 0 -0.3 mg /l SM 18 -20 3111B 09/25/15 MANGANESE (Mn <0.01 MG /L 0 -0.3 mg /l SM 18 -20 3111B 09/22/15 SODIUM (Na) 4.03 MG /L N/A SM 18 -20 3111B 09/25/15 0100 09/25/15 0103 * pH 7.6 UNITS 6.5 -8.5 SM18 -20 450OH13 09/18/15 HARDNESS,TOTA 80 MG /L N/A SM 18 -20 2340C 09/18/15 ALKALINITY (A 260 MG /L N/A SM 18 -20 2320B 09/14/15 0240 09/14/15 0245 TURBIDITY (TU <1 NTU 0 -5 NTU SM 18 (2130B) COMMENTS: oliform = This result indicates that the water (was), (was not) of a satisfactory sanitary quality according to t e New York State and EPA federal drinking water standard for this parameter. This comment applies to the Total Coliform test only. Pb /Cu LEAD limits for public schools are set at 15 ppb. EPA Lead & Copper Rule for Public Systems requires that no more than 10% of their distribution points have a LEAD value of more than 15 ppb and a COPPER value of 1.3 mg /L, else water treatment must be undertaken to reduce the waters corrosive potential. 6':a. /Mn If both iron and manganese are present, their total value combined shall not exceed 0.5 mg /L. IMS = IMMEDIATE METAL SAMPLE.(INTERPRETATION: WATER SAMPLED AFTER SITTING UNDISTURBED A MINIMUM OF 6 HOURS OR OVERNIGHT) NMS = NORMAL METAL SAMPLE. (INTERPRETATION: WATER SAMPLED AFTER RUNNING FOR 10 -15 MINUTES MINIMUM) YML ENVIRONMENTAL SERVICES 321 Kear Street Yorktown Heights, N.Y. 10598 (914) 245 -2800 Albert H. Padovani, Director ** TEST REPORT ** LAB #: 9.500519 CLIENT #: 64219 NON STAT PROC PAGE: 2 of 2 PATTERSON DEV PO BOX 839 MAHOPAC, NY CORP 10541 DATE /TIME TAKEN: 09/14/15 12:15P DATE /TIME RECD: 09/14/15 01:OOP REPORT DATE: 09/28/15 PHONE: (914)- 403 -6220 SAMPLING SITE: 34 BURTON FARM RD, PATTERSON NY SAMPLE TYPE..: POTABLE : KITCHEN TAP PRESERVATIVES: HNO3 COLD BY: MARK PORCELLI TEMP RECEIVED: 5.7C ON ICE NOTES...: COLIFORM METH: MF START DATE /TIME END DATE /TIME FLAG PROCEDURE RESULT NORMAL - RANGE METHOD Na No limits for Sodium are proscribed. suggested guidelines state that for people on a sodium restricted diet,the water should contain no more than 20 mg /L of Sodium. For those on a moderately restricted diet, a maximum of 270 mg /L of Sodium is suggested. * pH pH SCALE IN WATER RANGES FROM 1 -14. MEASUREMENT OF pH IS ONE OF THE IMPORTANT AND FREQUENTLY USED TESTS IN WATER CHEMISTRY. WATER WITH A LOW pH MIGHT BE CORROSIVE TO METAL PIPES AND FIXTURES. THE NORMAL RANGE OF pH IS 6.5 TO 8.5. pH IS A FIELD MEASUREMENT AND IS TESTED OUTSIDE THE HOLDING TIME. PH REPORTED FOR REFERENCE ONLY. Hd TOTAL HARDNESS IS DEFINED AS THE SUM OF THE CALCIUM & MAGNESIUM CONCENTRATION, BOTH EXPRESSED AS CALCIUM CARBONATE, IN MG /L. THE HARDNESS MAY RANGE FROM 0 TO HUNDREDS OF MG /L, DEPENDS ON THE SOURCE AND TREATMENT TO WHICH THE WATER HAS BEEN SUBJECTED. SOFT WATER: 0 -70 MG /L VERY HARD WATER: ABOVE 300 MG /L MODERATELY HARD WATER: 70 -140 MG/L, MG /L = MILLIGRAM PER LITER, HARD WATER: 140 -300 MG /L (1 grain /gallon = 17.2 MG /L) ALK (ALKALINITY REPORTED AT pH 4.5) IMS = IMMEDIATE METAL SAMPLE. (INTERPRETATION: WATER S nLE AFTE R SITTING UNDISTURBED A MI HOURS OR OVERNIGHT) THE ABOVE TE,(S Pry EDURE AND RELATE,uNLY 0 THESE SUBMITTED BY: �--� Albert H —P ov i, M.T Director ALL REQUIREMENTS OF NELAC, S RECEIVED BY THE LAB 0 ELAP# 10323 ALLEN BEALS, M.D., J.D. Commissioner of Health ROBERT MORRIS, P.E., MPH Director of Environmental Health August 27, 2015 DEPARTMENT OF HEALTH 1 Geneva Road, Brewster, New York 10509 Phone # (845) 808 -1390 Fax # (845) 278 -7921 MARYELLEN ODELL County Executive Dan Donahue P.E. Re: Field Inspection — Patterson Development 120 Breckenridge Road Burton Farm Road Mahopac, NY 10541 (T) Patterson, TM 65.18 -1 -74 Dear Mr. Donahue: A re- inspection at the above referenced lot has been completed. There are no open comments to be addressed at this time in reference to this Department's open work inspection. If you have any further questions, please contact me at (845) 808 -1390 ext. 43261. Sincerely, Gene D. Reed Principal Environmental Health Engineering Aide GDR:cw PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVERON1dMNTAL HEALTH SERVICES It y - Y C'3 0.2- z FINAL SITE INSPECTION Date: Inspected by: Street Location Modom Fmir wi 'iZc�-j Owner �� LYC ESN Town _ ' ,14_e rs0A Permit # •� - u.3 -- r TM # -3. /7 - ! - Fo Subdivision-Lot # 6 1. Sewage System Area a. STS area located as per approved plans ..........:......... . b. Fill section - date of placement 3:1.bam. er Lgth. Width .Avg.Dpth C.. Natural soil not stripped...... ....:........ ............................... d. Stone, brush, etc., greater than 15' from STS area.......... e. -100' from water course / wetlands ...... ............................... II. Sewage System a. Septiclank size - 1,000 .... ,250. other ................ b: ' Septic'tank installed level ..... ......................................... C. 10' minimum from £ oundation .......... ............................... d. Distribution Box 1.. All outlets at same elevation -water tested..' ­ 2. Protected below frost .................. ............................... 3. .. Nfinimum 2 ft.Original soil between box & trenches e. Junction Box properly set ......................................... 6. Trenclies 1. Length required 6 6 7 Length installed 4 6 7. 2. Distance to watercourse.measured -/- /00Ft.......... 3. Installed accordin g ro plan ......... ............................... 4. Slope of trench acceptable'1 /16 -1/32" /foot ............. 5. 10 ft. from property line - 20 ft.- foundations.......... 6. Depth of trench <30 inches from surface ................:. 7. Room allowed for expansion, 10.0 %..........:.. .............. 8: Size of gravel 3/4 - 1' /z" diameter . clean ................... 9. Depth of gravel in trench 12" minimum ................... 10. Pipe d ........ ............�....�...:......... . .......... g. Pump o se terns 7 1. Size p chamber ................. .............................. 2. Overflow tank .......................... ... ............................... 3. Alarm visual/ audio .........:........... ............................... 4. Pump easily accessible, manhole to grade ....... :......... 5. First box baffled.; ............................................... 6. Cyycle witnessed by H.D.estimated flow /cycle... III. House/Building a. Eiause located per approved ...... b Number of bedrooms ............................ !. ... IV. ?WeR Well located as per approved plans ................................. b. Distance from STS area measured ........... c. Casing 18" above grade ................ ........:...................... d. Surface drainage around well acceptable ....................... V. Overall Worlmanshin . a.. Boxes properly grouted ................... ............................... b. All pipes partially backfilled ........... ............................... c. All pipes flush with inside of box ... ............................... d. Backfill material contains stones <4" diameter .............. e. - Curtain drain & standpipes installed according to plan.. f. Curtain drain outfall protected & dinto exist watercourse g. Footing drains discharge away from STS area ............... h. Surface water protection adequate.... ....... ..............:......... i. Erosion control provided ................. ..............:........ ......... Rev. 12/02 SITE INSPECTION FOR FILL PAD Date: Inspected by:. Fill pad located per the approved plan Fill Pad Length Required Length_ ©� Fill Pad Width . Required Width 3 �� Fill Pad Depth Required Depth Run -of -Bank •Fill .Quality Slope from Top to Toe ct 7`��SKe Impervious Layer Installed e S X 7.6 = S 5 F Erosion Control Installed x z, o ►� Sieve Test Results (if applicable) — Additional Comments: • � �- mixes Reserved for Field Sketch if -Applicable ALLEN BEALS, M.D., J.D. Commissioner of Health ROBERT MORRIS, P.E., MPH Director of Environmental Health August 21, 2015 DEPARTMENT OF HEALTH 1 Geneva Road, Brewster, New York 10509 Phone # (845) 808 -1390 Fax # (845) 278 -7921 MARYELLEN ODELL County Executive Dan Donahue P.E. Re: Field Inspection — Patterson Development 120 Breckenridge Road Burton Farm Road Mahopac, NY 10541 (T) Patterson, TM 65.18 -1 -74 Dear Mr. Donahue: The above referenced separate sewage treatment system can be backfilled. The following comment must be corrected in the field: • A dose test needs to be witnessed by this Department. If you have any further questions, please contact me at (845) 808 -1390 ext. 43261. Sincerely; Gene D. Reed Principal Environmental Health Engineering Aide GDR:cw PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL IiEATLH SERVICES FIELD ACTIVITY REPORT ADDRESS: ataloyl ram 7d. 120C�vescot, Street Town State Zip i' 1► /1 WVA US «s ►. �. [; PUMP TEST aDOSE TEST 9i 3„ EL. START r � _ A EL. Signature and Title RFPORT RF-rFTVF -n RV• I acknowledge receipt of this report: SIGNATURE; 02/96 Rev. REQUIRED GALLONS 7( 6 2- s I U30 ILL- ' D. Q C o 3„ EL. START r � _ A EL. Signature and Title RFPORT RF-rFTVF -n RV• I acknowledge receipt of this report: SIGNATURE; 02/96 Rev. REQUIRED GALLONS 7( 6 2- s , n PUTNAM COUNTY DEPARTMENT -OF HEALTH { -- DIVISION OF ENVIRONMENTAL HEALTH SERVICES V-31" " CONSTRUCTION PERMIT FOR SEWAGE TREATMENT SYSTEM PERMIT # Located at )9 Z.. 0�fer,n 1'ecl C, j �rVillage Subdivision name /'Aubd. Lot # Tax Map �' Block _ Lot /7d Date Subdivision Approved Renewal Revision Owner /Applicant Name Mailing Address 3 6 5( z, -37 114 ffDate of Previous Approval /`i Zip Amount of Fee Enclosed SO Building TypeS.Aje:,, Lot Are��-No. of Bedrooms Design Flow GPD 6,00 Fill Section Only Depth Volume PCHD NOTIFICATION IS REQUIRED WHEN FILL IS COMPLETED Separates Sewerage System to consist of w1 9-0 gallon septic tank and Other Requirements: DDS', n To be constructed by -7 13 f7 Address Water Supply: Public Supply From or: 'L�XjS IltlPrivate Supply'Drilled by Address Address I represent that I am wholly and completely responsible for the design and location of the proposed system(s) and that the separate sewage treatment system described above will be constructed as shown on the approved amendment thereto and in accordance with the standards, rules and regulations of the Putnam County Department of Health, and that on completion thereof a "Certificate of Construction Compliance" satisfactory to the Public Health Director will be submitted to the Department, and a written guarantee will be furnished the owner, his successors, heirs or assigns by the builder, that said builder will place in good operating condition any part of said sewage treatment system during the period of two (2) years immediately following the date of the issuance of the approval of the Certificate of Construction Compliance of the original system or any repairs thereto,. f�`= . Signed: P.E. L R.A. Date Address %J6 �o �c /c'., f /�'� /z'l /ion,. f License # Y/ APPROVED FOR CONSTRUCTION: This approval expires two years from the date issued unless construction of the sewage treatment system has been completed and inspected by the PCHD and is revocable for cause or may be amended or modified when considered necessary by the Public Health Director. Any revision or alteration of the approved plan requires a new pe it. Approved fo scharge of domestic sanitary sewage only. B . J94 Title: �_ Date: W 'te opy - HD File; Yellow copy - 134ilding Inspector; Pink copy - Owner; Orange copy - Design Professional Form CP -97 MJT -NAM COUNTY DEPART141MM OF HWALTH D" 10N OF LrNMONWNTAL HKALTH SERVICES ArrnmoN . Mosion Q GFNE REQUEST-FOR FINAL INSMCIM For: Pill - - -- - - All infrnmabon must be fully completed prior to any . Trenches ,T mow• PCHD Constn�ion Permit Located•f vrlay, . Farms (V) Owner/Applicant Name: Aatj62k 6710 Block_ Lot Formerly: Subdivision Nerve: rr +► Subdivision Lot # Is system fill completed? Date: Is system complete? _.,� Dane: Is system constructed aswa plans? Is well drilled? x1c 17 i h Date: is well located as per plans? ZS Are erosion control u eesures in price? P I certify that the syswm(s), as 16tod, at the above premises bas been constructed and I bave inspected and verified their completion in acenrdarm with the issued PCHD Conssttuction Permit and approved plans and the Standards, Rules and Regulations of the Putnam County Depardment of Health. Date: %��',f" Certified by: PE RA Design Prefesional Address: & AK,1-+ r- e fP �Tr Lie. # T Comments: Form FIR -99 i CS-5A__ - -- - -- - - -- 3 U R T 0 N�; FARM e f O A DIC R -275 _-N 62i; 56'24'E 133.2 11.00' ' � ^ ! = 502 100EXp�' 1 � Pit PROP . SSTS ••ct +s oun.cT o.eo�K cosm CIWrBER w/ s CAL 0 S 3S PYC - s SwGKONC. 514 -� g' ~ 10.00' �• a /\C� t\ �� � osEO � i I \T FF ELEV 5�G�E' GF ELEV 514 \N�OQ'10�0 E Y PlS1ING WELL 517j.3X \\ \ PROPOSED WELL 46in. Tree 536.4 _ 1 I Oin. Tre I \ X b25.2 -LOT-& z:i Mar24 15 12:35p green turtle Cove 772 - 232 -8141 0, r - PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF .ENVIRONMENTAL HEALTH SERVICES DESIGN DATA SHEET - SUBSURFACE SEWAGE TREATMENT SYSTEM P.1 Owner: 04 r ,�f d$e ^ U,p Address: -3 Located at (street): /•�• ,Rc 7'M # % ' Z— MuMtelpality: All &-xcrt Watershed: je�•fx,4 SOIL, PERCOLATION TEST DATA Witnessed by: A t/ Date of Pre - soaking: _ ' ;� Date of Percolation. Test= fF Hole . No. Hole depth (1 nches) Run N {r_ Time Start — Stop Elapse Time (min.) Depth to water from ground surface (inches) Start - Ste Water level drop in inches Percolation Rate min/inch 3 Y _ '• . 3 S�� s ,�..i 6 4. i ' 1 3 4. 5 _ 2. J,;Like 3� 4 ` W/ i f r c2 - .7 S— Notes: 1. Tests to be repeated at same depth until aplxoximately equal percolation rates are obtained at each percolation test hole. (i.e., < 1 min for 1-30 min/inch, ti 2 min ibr 31-60 min inch), All data to be submittal for review. 2. Depth mew- wreamonts to be made, from top of hole. form DD -97, pg t of 2 Mar24 15 12:36p green turtle Cove 772- 232 -8141 p.2 . TEST PIT DATA DCSCRIMON OF SOMS.ENCOUNTMED IN TEST HOLES DEPTH HOLE # _ HOLES HOLD # - .. ._ HOLE #, � HOLE # G.L 1.0' 2 -O' 2.5' +rZ. 3.5' 4.5' 5.5' 7.0' 7.5' 13.5' 9.5' • 90.Or • indicate level at which groundwater is encourrtcred .. Allg'0 Indicate level at which mOtft is observed 4 Indicate level to which writer level rises after a>ter being eac entered .P _ Deep hole observations made by: _ l hate 3 /may Design Professional Name, iD&O r u 1...ti .Address: 1"'A/ fcAl -e e i d l , zaJ Signature: Design Praiesalonsl's Seal Rovixw Judy 2013 ALLEN BEALS, M.D., J.D. Commissioner of Health ROBERT MORRIS, P.E., MPH Director of Environmental Health March 13, 2015 DEPARTMENT OF HEALTH 1 Geneva Road, Brewster, New York 10509 Phone # (845) 808 -1390 Fax # (845) 278 -7921 Daniel J. Donahue, P.E. 120 Breckenridge Road Mahopac, NY 10541 Dear Mr. Donahue: MARYELLEN ODELL County Fxecutive Re: Proposed SSTS — Patterson Development Burton Farm Road (T) Patterson, T.M. 3.19 -1 -90 This office has received and reviewed the most recent set of plans for the above- mentioned project. We would like to offer the following comments for your review and consideration. 1. A dosing siphon is required along with a dosing siphon detail. 2. The absorption trench detail is to note the pipes are to be laid level. 3. The new deep and percolation test hole locations are to be shown. 4. A design data sheet with the new testing is to be provided. 5. The SSTS profile is showing drop boxes and it doesn't show the existing grade. 6. Why is fill being proposed? If it is for grading purposes, it appears to be an excessive amount of fill 7. Fill notes need to be provided. This office will continue its review upon consideration of the above - mentioned comments. Please feel free to contact me at ext.43157 if any questions arise. Sincerely, i S. Paravati, Jr.,. P.E. ant Public Health Engineer JSP:cml r DOW- CB-5A R M � �f O A D� R =275 FA 3 U R T O N \, / CB -3 V L .a CB -5 M 88 56'24" E 133.2 , r 11.00' :.�; !�` h kA of_:.....: 9—�`°� l 503.2..E =,,� /1 500 i /. / % /p / �!. 502-x- ( PNSio� i f LLJ 100%, 2 / / f ` 6 y'� //510 i W 4 2 ' z �+ f X506 ° I PRA/ � 1 i JIG t I — - � — I —� MPRY yF • � O 3 pR� 66 j 508 O i —� x512.0 III f l 15 OUTLET I .D.B OX with _siphon 1250 GAL CON CRE 4" SOR35 PVC SEPTIC TA' - N ` K 1000' a' cl — 4f `1I j 514 I / , ` OSED BEDROO"OUSE � / I \ N�BQ'10�" E 10�' j I � � i � I •oo. I �o PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES DESIGN DATA SHEET - SUBSURFACE SEWAGE TREATMENT SYSTEM Owner: Address: ��2 � rjf Located at (street): TM # Municipality: Watershed: A5X--,57— SOIL PERCOLATION TEST DATA Witnessed by: Date of Pre - soaking: 3 3 Date of Percolation Test: ' 3 Z 3 Z / Hole No. Hole depth (Inches) Run No. Time Start - Stop Elapse Time (min.) Depth to Water from ground surface (inches) Start - Stop water level drop in inches Percolation Rate min /inch 2.7 3 2 ,Z7 3 5 2 `!G - 2' J(e, 3V 22 -2� ` O 4 5 3 --s 30 z -:ZfI . 2 12,136 3 °' 3C7 4 5 2 - 7 ;2- 7 3, ��-- 3 ,z °- i ©� - �- 4 °2- 7 5 Notes: 1. Tests to be repeated at same depth until approximately equal percolation rates are obtained at each percolation test hole. (i.e., < 1 min for 1 -30 min/inch, < 2 min for 31 -60 minlinch). All data to be submitted for review. 2. Depth measurements to be made from top of hole. Form DD-97, pg 1 of 2 TEST PIT DATA DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES DEPTH HOLE # 3 HOLE # --�/ HOLE # HOLE # G.L. 0.5' 1.0' 2.0'_ 3.0' 3.5' 4.0' 4.5' 5.0' 5.5' . 6.0' 6.5' 7.0' 7.5' 8.0' 8.5' 9.0' 9.5' 10.0' HOLE # Indicate level at which groundwater is encountered it11,0(¢ Indicate level at which mottling is observed _ 4 Indicate level to which water level rises after being encountered IU %s9 Deep hole observations made by: . ��`j Date / y Design Professional Name: Address: Signature: Design Professional's Seal I Revised July 2013 ALLEN BEALS, M.D., J.D. Commissioner of Health ROBERT MORRIS, P.E., MPH Director of Environmental Health DEPARTMENT OF. HEALTH 1 Geneva Road, Brewster, New York 10509 February 20, 2015 Phone # (845) 808 -1390 Fax # (845) 278 -7921 Daniel J. Donahue P.E. 120 Breckenridge Road Mahopac, NY 10541 Re: Complete Application Determination for Patterson Development Burton Farm Road (T) Patterson, TM 3.19 -1 -90 East Branch Reservoir Basin Dear Mr. Donahue: MARYELLEN ODELL County Executive The Putnam County Department of Health (Department) has determined that the above referenced application, including fee, and revisions received by this Department on February 20, 2015 is complete. The Department will notify you by March 13, 2015 of its determination. 9 The Project has been delegated to the Putnam County Health Department for review pursuant to the guidelines set forth in the Watershed Agreement. ❑ Joint review with the NYCDEP will commence pursuant to the guidelines set forth in the Watershed Agreement. If the Department fails to notify you within the above referenced time frame, you may notify the Department of its failure by certified mail, return receipt requested. The notice should be sent to my attention at the above address. This notice must include your name, the location of the project, the office with which you filed the application originally, and a statement that a decision is sought in accordance with section 18 -23 (d) (6) of the NYC Dept. of Environmental Protection Watershed Rules and Regulations. If the Department fails to notify you within 10 days of the receipt of the notice, your application will be deemed approved, subject to standard terms and conditions as set forth in the regulations. Please be advised that projects within the NYC Watershed may also require Department of Environmental Protection review and approval of other aspects of a project, such as stormwater plans or the creation of impervious surfaces, and the project applicant should contact the Department of Environmental Protection regarding such activities to see if Department of Environmental Protection review and approval is required. If you have any questions regarding this matter, please call me at (845) 808 -1390 ext. 43157. JSP:cml Respectfully, ;Jot h S. Paravati Jr., P.E. ant Public Health Engineer ALLEN BEALS, M.D., J.D. Commissioner of Health ROBERT .MORRIS, P.E. Director of Environmental Health DEPARTMENT OF HEALTH 1 Geneva Road, Brewster, New York 10509 Phone # (845) 808 =1390 Fax # (845) 278 -7921 MARYELLEN ODELL County Executive TO: NYCDEP DEPARTMENT OF ENGINEERING AND DESIGN REVIEW FROM: DELEGATION STATUS FOR SUBSURFACE SEWAGE TREATMENT SYSTEM PROGRAM DELEGA TED New Application`` Renewal El r S l 1 , PROJECT: LOCATION: % TOWN: DATE SUB'D APPROVAL l TM# 3• NOTICE OF COMPLETE APPLICATION DATE: DELEGATED G PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES APPLICATION FOR APPROVAL OF PLANS FOR A WASTEWATER TREATMENT SYSTEM 1. Name and address of applicant: P- x De -e to 41 � � /tea `\!- L7 e . 2. Name of project: S/&,c t-, P��!.0 IWC 3. Locati0ov: 10R'7' 74P r V d y, 4. Design Professional: , d /I� 5. Address: ,li a f3 6. Drainage Basin: 7. Type of Project: _X Private/Residential Food Service Apartments Institutional Office Building Realty Subdivision ¢ Commercial Mobile Home Park Other (specify) 8. Is this project subject to State Environmental Quality Review (SEQR)? Type Status check one .............. Type I Exempt Type II Unlisted 9. Is a Draft Environmental Impact Statement (DEIS) required? .......A. 10. Has DEIS been completed and found acceptable by Lead Agency? .`J. 11. Name of Lead Agency /V- 12. Is this project in an area under the control of local planning, zoning, or other officials, ordinances? ......................................................... ............................... mil' 13. If so, have plans been submitted to such authorities? ........ ............................... 14. Has preliminary approval been granted by such authorities? Date granted: ltl 15. Type of Sewage Treatment System Discharge ................. surface water x groundwater 16. If surface water discharge, what is the stream class designation? .................... 17. Waters index number (surface) ........................................... ............................... 18. Is project located near a public water supply system? ...................................... 19. If yes, name of water, supply Distance to water supply Nf/�- 20. Is project site near a public sewage collection or treatment system? ................ /(( d 21. Name of sewage system Distance to sewage system 22. Date test holes observed /oA Dy` 03 23. Name of Health Inspector Flo, AA 4, "-t-4z 24. Project design flow (gallons per day) 606 25. Is State Pollutant Discharge Elimination System ( SPDES) Permit required ?... X10 26. Has SPDES Application been submitted to local DEC office? .............. x' � :o 2 27. Is any portion of this project located within a designated Town or State wetland ?i a 28. Wetlands ID Number..:....:: �. � ..........................:..................... ......................:........ 29. Is Wetlands Permit required`?; . ................. � •••••••••••••• Ale ��-- Has application been made to Town or Local DEC office? ...... .. ........................ nl 30. Does project require a DEC Stream Disturbance Permit? .. ............................... &,�q 31. Is or was project site used for agricultural activity involving application of pesticides to orchards or other crops, solid or hazardous waste disposal, landfilling, sludge application or industrial activity? ............................ Yes/No Je e 32. Is project located within 1,000 feet of existing or abandoned landfill, hazardous waste site, salt stockpile, landfill, sludge disposal site or any other potentially known source of contamination? ............................... Yes/No DESCRIBE: 33. Is there a local master plan on file with the Town or Village? ......................... es 34. Are community water and/or sewer facilities planned to be developed within 15 years in or adjacent to project site? ................................ ............................... 1 y 35. Are any sewage treatment areas in excess of 15% slope? .. ..............................� 36. Tax Map ID. Number .......................... ............................... Mapq.—/t Block / Lot 37. Approved plans are to be returned to ..... X Applicant Design Professional NOTE: All applications for review and approval of a new SSTS to be located within the NYC Watershed shall be sent to the Department, and need not be sent in duplicate to the DEP, although the project may require DEP approval of the SSTS prior to final approval by the Department. Projects within the watershed may also require DEP review and approval of other aspects of a project, such as stormwater,plans or the creation of impervious surfaces, and the project applicant should obtain the appropriate formsafor such activities from DEP and submit those forms to DEP for review and approval. If the application is signed by a person other than the applicant shown in Item I.,the application must be accompanied by a Letter of Authorization (Form LA -97). Failure to comply with this provision may be grounds for the rejection of any submission. I hereby affirm, under penalty of perjury, that information provided on this form is true to the best of my knowledge and belief. False statements made herein are punishable as a Class A misdemeanor pursuant to Section 2 5 of the P na Law. SIGNATURES & OFFICUL TITLES. - 2�-, ell J? f Mailing Address: ................................... ,� ,� D f3 r 117 4 PL NI ANI COLTN"TY DEPARTMi EN'T OF HEALTH DIVISION OF EN -V RONIVIEVTAL HEALTH SERVICES DESIGN' DATA SHEET — SLBSL'RFACE SEWAGE TREATMENT SYSTEM Owner: �� �� �/� !� ,� I Je..I �G�O%�i�T Address:��� `' fS'�% ��a �PO�w y., Located at (street): Re, Aw FO!r/yt ee-� 4 J- TM 4 Section3" 1%lock % Lot %® Municipality: '% °�.('�y Watershed: SOIL PERCOLATION TEST DATA Witnessed by: �• ����.r Date of Pre - soaking: r h _ Date of Percolation Test: i Hole Rio. i Run No. Time Start — Stop Elapse Time (min.) Depth to water from ground surface (inches) Start : Sto " ' Water , level drop in inches i Percolation Rate min/inch ! l 3 I "r I � I s ! ! I { I i 5 a 0 I Z c 0 2- 3, J- I 4 a'3 3' I o 2j _ 3 =� s. i I 3i ,10/I I ©ate I l a.3 2 I f 4 I I ! I s ! 2 f f 3 I 1 4 l I s Notes: 1. Tests-to be repeated at same depth until approximately equal per colation -aces are obtained at each perco(arion test hole. (i.e., < 1 Emit for 1 -30 min/inch, 5 2 Enin for 3 i -60 mirv;nch 5 4 PUTNAVI COUNTY DEPARTMENT OF HEALTH DI'VTSION OF ENVIRONMENTAL HEALTH SERVICES DESIGN DATA SHEET - SLBSb TFACE SEWAGE TREAT'MEI TT SYSTEM Owner: �� d �b c- l� l wi,�e �°lJ Address: �e-%t Located at (street): yv -17 -r 1-7— /Q� c d ✓ TM 4 Section3�lock / Lot 7Z Municipality: Watershed: CY617�-`I SOIL PERCOLATION TEST DAT:� Witnessed by: Date of Pre - soaking: 11,6 �% Date of Percolation Test: f Hole No. Run No. Time Start — Stop Elapse Time (min.) Depth to . water from ground surface (inches) Start - Stop Water level drop in inches Percolation Rate min /inch i 2 dsY I 3vY ( 2a I 3 l i s I 34 Q3 off' f 20 ! 4 I ( 1 ! s 1 d 11A6 > s— 3 I 2 c;Ljr— 3 I z� '� 3 v 2 2 K, 7j— I ? L I 4 -2 I 2 I 1 3 I 4 ! { I s! I I l Ir 3 I ! 4 l I I j ( s! f I I I 1 Votes: t. Testa to be repeared at same depth until approximately equal percolation rates are obtained at each percolation test ho(e. (i.e., < t min for 1-30 min inch, <? min for 3 1-60 miniinch). r.i PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES DESIGN DATA SHEET — SUBSURFACE SEWAGE TREATMENT SYSTEM Owner: / cr c� Z � 1,t�ore .11 Address: Located at (street): B y v - L , E4 ✓ TM # Municipality: Rct �7��- se'l Watershed: SOIL PERCOLATION TEST DATA f n Witnessed by: Date of Pre- soaking: G Date of Percolation Test: Hole No. Hole depth (Inches) Run No. Time Start — Stop Elapse Time (min.) Depth to water from ground surface surface Start - Stop Water level drop in inches Percolation Rate min/inch 3 1 7 / /� .1v, rra -2•,r 2 t ° /J- �- 3 v °8 -/ o �, 4 /s a c/7 a7 3 5 �0 1 2 �,-- 3 16 36 )L 47, z 4 5 1 2 3 4 5 1 2 3 4 5 Notes: 1. Tests to be repeated at same depth until approximately equal percolation rates are obtained at each percolation test hole. (i.e., < 1 min for 1 -30 min/inch, < 2 min for 31 -60 min/inch). All data to be submitted for review. 2. Depth measurements to be made from top of hole. Form DD-97, pg 1 of 2 • k� PUTNA -ICI COUNTY DEPAR'TNIENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES DESIGN DATA SHEET - SUBSURFACE SEWAGE TREAT.NfENT SYSTEM' Owner: C d �oc�C !� ft'�v 1/t?s - �G�k'rE', /T Address: Pee6 d)l �3 � /1ifl,./i1 4� �%`1 9 Located at (street): �;��' {ny� �'r'�, ��' f TM 4 Section :3, /f1Block Lot �d ;Municipality: P--, . / e,- r&� Watershed: 7�>i SOIL PERCOLATIOti TEST DATA Witnessed by: " Date of Pre - soaking: G Date of Percolation Test^ ,cam Hale N"o. Run No. Time Start — Stop Elapse Time (min.) Depth to water from round g surface (inches) Start - Stop Water level drop in Inches Percolation Rate min /inch { 2 S- i 4 � I � z I l E 2 3 I j { 4 { 5. I i 2 4 s I I { f 2 3 4 i s { I I Notes: 1. Tests to be repeared at same depth until approximately. equal percolation rotes are obtained at each percolation test hate. (i.e., < l min for 1 -30 miniinch, <2 min for 3 i -64 mintinchi. d N Anrn rn !.P anhm;,mo.4 f— rn ,;—, I� . r DEPTH ti.L. 0.5' 1.0' 1.5' 2.0' 2.5' 3.0' 3.5' 4.0' 4.5' 5.0' 5.5' 6.0' 6.5' 7.0' 7.5' 8.0' 8.5' 9.0' . 9.5' 10.0' 'TEST PIT DATA DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES HOLE NO. / . HOLE NO. 2-"' HOLE NO. Indicate level at which groundwater is encountered AAX-, Indicate level at which motding is observed Indicate level to which water level rises after be_ ing countered Deep hots observations made by: Date Design Professional. Name:J Address: '..- �,',ir� �d ��o S810 Desip o ti o CP �0. 4B 2 .7 t- - N 14 -i6-4 P87)—Text 12 PROJECT I.D. NUMBER 617.21 SEOR Appendix C State Environmental Quality Review SHORT ENVIRONMENTAL ASSESSMENT FORM For UNLISTED ACTIONS Only. PART I— PROJECT INFORMATION (To be completed by Applicant or Project sponsor) 1. APPLICANT iSPONSOR 2. PROJECT NAME / 3. PROJECT LOCATIONLea Pl Municipality --(--,, -p<#( County 4. PRECISE LOCATION (Street address and road Intersections, prominent landmarks, etc., or provide map) 5. IS PROPOSED ACTION: 0 New ❑ Expansion ❑ Modification/alteration 8. DESCRIBE PROJECT BRIEFLY: Cv,r is % RV G / [V �v L 7. AMOUNT OF LAND AFFECTED: 01 1— Initially acres Ultimately r .} acres 8. WILL PROPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER EXISTING LAND USE RESTRICTIONS? MYes CJ No it No, describe briefly 9. WHAT IS PRESENT LANG USE IN VICINITY OF PROJECT? CVResidenlia! G industrial ❑ Commercial ❑ Agriculture ❑ Park/Forest/Open space ❑ Other Describe: 1C. DOES ACTION INVOLVE A PERMIT APPROVAL, OR FUNDING, NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY (FEDERAL STATE R LOCAL)? 1 ZYes ❑ No It list agency($) and permlt/approvals yes, ii. DOES ANY ASPECT OF THE ACTION HAVE A CURRENTLY VAUD PERMIT OR APPROVAL? ❑ Yes L:J No it yes, list agency name and permitlapproval 12. AS A RESULT OF PROPOSED ACTION WILL EXISTING PEAMIT /APPROVAL REQUIRE MODIFICATION? ❑ Yes No I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE Applicantisponsor name: �Al l� L �' �� N /4 U re ' ^ Date: !� Signature: rzol� If the action is in the Coastal Area, and you are a state agency, complete' the Coastal Assessment Form before proceeding with this assessment OVER 1 PART 11— ENVIRONMENTAL ASSESSMENT (To be completed by Agency) A. DOES ACTION EXCEED ANY TYPE I THRESHOLD IN 6 NYCRR, PART 617.12? If yes, coordinate the review process and use the FULL EAF. k ❑ Yes No B. WILL ACTION RECEIVE COORDINATED REVIEW AS PROVIDED FOR UNLISTED ACTIONS IN 6 NYCRR, PART 617.6? if No, a negative declaration may be superseded by another Involved agency. . ❑Yes ntNB C. COULD ACTION. RESULT iN ANY ADVERSE EFFECTS ASSOCIATED WITH THE FOLLOWING. (Answers may be handwritten, If legible) Ct. Existing air quality, surface or groundwater quality or quantity, noise levels, existing traffic patterns, solid waste production or disposal, potential for erosion, drainage or flooding problems? Explain briefly CZ_ Aesthetic, agricultural, archaeological, historic, or other natural or cultural resources;.or community or neighborhood character? Explain briefly: h(�Al i . C3. Vegetation or fauna, fish, shellfish or wildlife species, significant habitats, or threatened or endangered species? Explain briefly: 14V v IV C4. A community's existing plans or goals as officially adopted, or a change in use or intensity of use of land.or other natural resources? Explain Na Al C5.' Growth, subsequent development, or related activities likely to be induced'V the proposed action? Explain briefly. /Mawr C6. Long term, short term, cumulative, or other effects not identified in Ci.C5? Explain briefly. C7. Other impacts (including changes In use of either quantity or type of energy)? Explain briefly. /V& "V de D. IS THERE. OR IS THERE LIKELY TO BE, CONTROVERSY RELATED TO POTENTIAL ADVERSE ENVIRONMENTAL IMPACTS? C3 Yes icy No If Yes, explain briefly PART III — DETERMINATION OF SIGNIFICANCE (To be completed by Agency) INSTRUCTIONS: For each adverse effect identified above, determine whether it is substantial, large, important or otherwise significant. Each effect should be assessed in connection with Its (a) setting (i.e. urban or.ruraly,.(b) probability of occurring; (c) duration; (d) irreversibility; (e) geographic scope; and (f) magnitude. If necessary, add attachments or reference supporting materials. Ensure that explanations contain sufficient detail to show that all relevant adverse Impacts have been Identified and adequately addressed. ❑ Check this box if you have Identified one or more potentially large or significant adverse impacts which MAY occur. Then proceed directly to the FULL EAF and/or prepare a positive declaration. ❑ Check this box if you have determined, based on the Information and analysis above and any supporting documentation, that the proposed action WILL NOT result in any significant adverse environmental impacts AND provide on attachments as necessary, the reasons supporting this determination: PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES .LETTER OF AUTHORIZATION RE: Property of d°Q r�s� u DP va AiPA1 6, ry .-/ Located at q Ov P�Y7� ��r s 0,7 Tax Map # '3, /'F - %' 70 Subdivision of Subdivision Lot # Filed Map # _ Date Filed dvc� To whom it may concern: This letter is to authorize A duly licensed Professional Engineer or Registered Architect to apply for the required wastewater treatment and/or water supply permits(s) to serve the above -noted properly in accordance with the standards, rules or regulations as promulgated by the Commissioner of Health of the Putnam County Department of Health, and to sign all necessary papers on my behalf in connection with this matter and to supervise the construction of said wastewater treatment and/or water supply systems in conformity with the provisions of Article 145 and/or 147 of the Education Law, the Public Health Law,,,,AN the Putnam County Sanitary Code. Countersigned: Signed: (Design pr ssional)/ er of pr perry) 1) 4 h e e l D, k 4 / te- ��it�' (Print name) - (Pant name) P.E., R.A., #�L%� / Mailing Address: /2 C A a c State /V % Zip Telephone: Date: Email: Mailing dress: 1/ 0 State 6V Zip 0 Telephone: Revised July 2013 kly VDQ I[EUTE12 VF M&ROOMUL CUNSULTIN ENGINE ❑ Daniel 1. Donahue, P.E. 200 Breckenridge Road Mahopac, N.Y. 10541 914-628-7576 WE ARE SENDING YOU ❑ Attached ❑ Under separate cover via DATE JOB NO. ATTENTIO RE kfp.,p // C-4 Az f•V OrMf jl:�r ❑ Shop drawings )d Prints Al Plans ❑ Samples ❑ Copy of letter ❑ Change order ❑ the following items: ❑ Specifications COPIES DATE NO. DESCRIPTION kfp.,p // C-4 Az f•V OrMf jl:�r V49P s, f * Dv -14 l Lip, 1""orlz 'fAPwe'4-1tz 0 SI&PT L. V -F lqw, A/ V S lv"Mx� ot A� THESE ARE TRANSMITTED as checked below: ❑ For approval ❑ For your use ❑ As requested ❑ For review and comment ❑ FOR BIDS DUE - REMARKS ❑ Approved as submitted ❑ Approved as noted ❑ Returned for corrections 19 ❑ Resubmit copies for approval ❑ Submit copies for distribution ❑ Return -corrected prints ❑ PRINTS RETURNED AFTER LOAN TO US COPY TO SIANFn-